“Health records are meant to convey necessary information to all people involved in an animal’s care. Every facility is expected to have a system of health records sufficiently comprehensive to demonstrate the delivery of adequate health care. For all facilities, health records must be current, legible, and include, at a minimum, the following information:
- Identity of the animal. *
- Descriptions of any illness, injury, distress, and/or behavioral abnormalities and the resolution of any noted problem.
- Dates, details, and results (if appropriate) of all medically-related observations, examinations, tests, and other such procedures.
- Dates and other details of all treatments, including the name, dose, route, frequency, and duration of treatment with drugs or other medications. ( A “check-off” system to record when treatment is given each day may be beneficial.)
- Treatment plans should include a diagnosis and prognosis, when appropriate. They must also detail the type, frequency, and duration of any treatment and the criteria and/or schedule for re-evaluation(s) by the [unit] attending veterinarian. In addition, it must include the [unit] attending veterinarian’s recommendation concerning activity level or restrictions of the animal.
Examples of procedures which should be adequately documented in health records include, but are not limited to, vaccinations, fecal examinations, radiographs, surgeries, and necropsies. Routine husbandry and preventive medical procedures (e.g., vaccinations and dewormings) performed on a group of animals may be recorded on herd-health-type records. However, individual treatment of an animal must be on an entry specific to that animal. As long as all required information is readily available, records may be kept in any format convenient to the licensee/registrant (e.g., on cage cards for rodents).
…[I]t is the responsibility of the licensee/registrant [i.e., NC State] to ensure that all components of the records are readily available and that the record as a whole meets the requirements listed above.
An animal’s health records must be held for at least 1 year after its disposition or death. (Note: Some records may need to be held longer to comply with other applicable laws or policies.) When an animal is transferred to another party or location, a copy of the animal’s health record must be transferred with the animal.”
* Identity of animal interpreted to mean positive individual identification, specific location of an isolated animal, or appropriate identification of herds, flocks, etc.
According to the Animal Welfare Act regulations, the program of veterinary care must include “…a mechanism of direct and frequent communication…so that timely and accurate information on problems of animal health, behavior, and well-being is conveyed to the attending veterinarian.” The need for direct involvement by a veterinarian in health/medical record keeping will vary with the situation and, under some circumstances, may be met by documented telephone or email correspondence or reference to written SOPs (e.g., for preventive medicine programs) developed in consultation with the unit attending veterinarian.
Each NC State animal resource unit must develop and maintain, in consultation with the attending veterinarian for that unit, a system for medical record keeping which is consistent with the above policy. Format for medical records is flexible, as long as required elements are documented and clear. Assistance in implementation of this policy, or any aspect of veterinary care for NC State research and teaching animals is available from the IACUC Office, 919.515.7507 or the University Attending Veterinarian, Dr. Nneka George, 919.513.2365.
July 11, 2000, updated October 26, 2009, last checked September 7, 2017